[Laparoscopic treatment of mechanical small bowel obstruction]. / Traitement laparoscopique des occlusions mécaniques du grêle.

BACKGROUND: A history of abdominal surgery have long been considered a contraindication to laparoscopy. There was a reluctance to advocate the use of laparoscopy in mechanical bowel obstruction due to technical difficulties related to a distended small intestine, and a small work space. AIMS: To report the results of laparoscopic treatment of small bowel mechanical obstruction and to study the factors for conversion to laparotomy. METHODS: Our study is retrospective, having compiled 32 patients between January 2001 and December 2009. The average age was 35 years (20-54). There were 17 men and 15 women. History of laparotomies were noted in 27 patients. Were excluded from this study patients with strangulated hernia or eventration. An analysis was conducted to determine the conversion factors to laparotomy RESULTS: The flanges or postoperative adhesions were responsible for 27 of the 32 intestinal obstructions (84%). In 24 cases there was a single flange or localized adhesions treated by simple section successfully in 18 patients (56% of cases). A conversion was performed in 14 cases (44%). the median time to recovery of intestinal transit was shorter after laparoscopic surgery completely after conversion (1.5 vs. 2.5 days, p = 0.004). Similarly, the median length of postoperative stay was shorter in the absence of conversion (2.4 vs 7, p <0.001). Statistical analysis identified four factors related to conversion, which are: the presence of peritoneal signs, the number of brackets> 1, and the need for a bowel resection. CONCLUSION: Laparoscopy is an option for the treatment of mechanical bowel obstruction when performed in selected patients. His best indication could be the occlusion of single flange. This alternative to laparotomy could reduce adhesion formation and potentially reduce future episodes of obstruction.

[Early diagnosis of anastomotic dehiscence after colonic surgery]. / Diagnostic precoce du lachage anastomotique apres chirurgie colique.

BACKGROUND: Anastomotic leaks are often responsible for severe sepsis can lead to death. Rapid diagnosis and early intervention are needed to improve prognosis. AIM: To identify predictors of early diagnosis of anastomotic leakage after colonic resection followed by immediate anastomosis without protective stoma to ensure a rapid therapeutic care and improve prognosis. METHODS: This retrospective study involved patients who had a colonic resection over a period from 1st January 1998 to December 31st, 2009. The diagnosis of anastomotic dehiscence was selected on clinical, radiological and / or surgery. Statistical analysis was undertaken to identify clinical and biological changes leading to early diagnosis. The significance level was set at 0.05. RESULTS: Anastomotic leaks were identified in 28 patients, a rate of 8.9%. Revision surgery was indicated in 23 patients. Univariate analysis identified 3 preoperative factors associated with anastomotic dehiscence (ASA score, the urgency of intervention, and neoplastic etiology), and 5 postoperative factors (parietal complications, respiratory problems, the cardiac disorders, neurological disorders, and bloating). Multivariate analysis identified only three factors related to the anastomotic dehiscence, they were respiratory symptoms, bloating, and neurological disorders. The median length of stay was 15.6 days (5-84). The mortality rate was 1.2%. It was higher in patients with leakage (7.4%) than in patients without leakage (0.7%). CONCLUSION: Better knowledge of these early clinical and laboratory manifestations related to anastomotic leaks, can ask the early indication of a radiological drainage or reoperation, which can improve the prognosis of this dreaded disease.

[Laparoscopic management of abdominal wounds]. / Prise en charge laparoscopique des plaies de la paroi abdominale antérieure par arme blanche.

BACKGROUND: The management of abdominal wounds apart from an extreme emergency remains controversed. Means vary between explorative laparotomy and mere monitoring. Between these two extreme cases, laparoscopy as an exploration means plays a significant role, by avoiding laparotomy and by establishing the early diagnosis of lesions. AIM: The objective of this study is to report our experience in laparoscopic management of frontal abdominal wounds caused by a blank arm. PATIENTS AND METHODS: Between January 2004 and December 2008, 61 patients with 27-year average age showing anterior abdominal wounds caused by a blank arm, with stable hemodynamic status have been subjected to a laparoscopic exploration. RESULTS: Laparoscopic exploration revealed a penetrating wound in 36 patients (59% of cases) of whom 27 had perforating wound. Six patients had a frontal abdominal wound, of which four have required a thoracic drainage in addition to the laparoscopic exploration of abdominal cavities. Two patients had a left diaphragmatic wound. Twelve patients (19.7%) have required a therapeutic action that consisted in an electro coagulation of filled organs, a simple suture or a resection-anastomosis for the digestive tract, and suture of diaphragmatic wounds. A conversion was performed in 7 patients (11.5%). The death rate was nul. Morbidity rate was 3.2%. Average hospitalization course was 2.54 days. CONCLUSION: Laparoscopy is a safe and efficient means for exploration of abdominal cavity in patients showing a frontal abdominal wound. It allows avoiding a systematic or useless laparotomy in 88.5% of wounded individuals and then allows to trait some lesions without recours to laparotomy.

[Management of sigmoid volvulus]. / Prise en charge du volvulus du sigmoïde.

AIM: The objective of this work paper is to report our experience in the management of the sigmoid volvulus. METHODS: This retrospective study relates to 40 cases of sigmoid volvulus operated in Surgical Departments B of Rabta University Hospital, Tunis, from January 1999 to December 2008. It refers to 35 men and 5 women, of 55 years as average age. Twenty six patients have been subjected to a volvulus removal through rectosigmondoscopy, which allowed a untwisting of the volvulus in 23 cases. Those patients have been subjected to a colorectal anastomosis within an average 9 day term. Among those patients, 5 subjects have undergone a sigmoidectomy assisted by laparoscopy. Urgent laparotomy has been performed in 17 patients following failure or complication of the endoscopy (3 cases), or straightaway laparotomy (14 cases) which showed a colic necrosis in 10 cases, of which 4 cases had stercoral peritonitis. One patient had a pre perfrorative lesions on right colon has been subjected to a total colectomy, followed by an ileorectal anastomosis. A sigmoidectomy has been performed in 16 patients, followed by a colorectal anastomosis (n = 2), an Hartman intervention (n = 4) and a double stomy (n = 10). All those patients have had restoration of digestive continuity within an average 90 days term. RESULTS: Postoperative complications have consisted in 5 pneumopathy cases, 2 heart insufficiency cases, 3 urinary tract infection cases and on peristomial eventration case. No patient has showon an anastomotic loosening or a recurrence after elective surgery. The average follow-up duration was 110 days. Four deaths have occurred immediately after urgent laparotomy. This relates to a state of septic shock with multiple organ failure (n = 2), a lung embolus (n = 1) and a pneumapatty (n = 1) CONCLUSION: The best treatment for sigmoid volvulus consists to an endoscopic volvulus removal intervention followed by a sigmoidal resection during the same hospitalization period. Urgent laparotomy is indicated in case of signs of necrosis or failure of endoscopy. Sigmoidal resection without immediate restoration of digestive continuity is recommended in presence of risk factors of anastomotic loosening.

Pancreaticoduodenectomy in the elderly over 80 years: a case report.

BACKGROUND: An increasing number of elderly patients have been considered for major surgical procedures, such as pancreaticoduodenectomy. The decision to recommend this operation for localized pancreatic cancer or other periampullary process in a very elderly patient is complicated by the frailty of the patient and the poor prognosis of the disease. Moreover, increased surgical experience associated with better patient selection may reduce the mortality rate, even in very elderly patients (over 80 years of age), after pancreaticoduodenectomy. METHODS: An 84-year-old woman underwent pancreaticoduodenectomy for ampullary adenocarcinoma. The tumor was classified pT3N0M0. RESULT: A good postoperative outcome was obtained. The patient is still alive, 18 months after operation. CONCLUSIONS: Radical resection of periampullary tumors is safe in selected patients of advanced age, with morbidity and mortality rates approaching those observed in younger patients. Age alone should not be a contraindication for pancreatic resection.

[Inflammatory fibroid polyp of the ileum presenting as intussusception: a case report in an adolescent]. / Polype fibro-inflammatoire de l'intestin grele revele par une invagination intestinale aigue: a propos d'un cas chez une adolescente.

Inflammatory fibroid polyp is an uncommon and benign submucosal lesion of the gastrointestinal tract. The maximal incidence is in the fifth and sixth decades. The main histological characteristics are diffuse inflammatory infiltrate with eosinophils and highly vascularized fibrocystic stroma. We report a case of 15-year-old patient who underwent emergency surgery because of acute intestinal obstruction as a result of an intussusception. The macroscopical study after segmental ileal resection showed a nodular lesion 3x2x2 cm, arising from the submucosa with an ulcerated surface. The pathologic diagnosis was ileal inflammatory fibroid polyp. Immunohistochemically, the cells reacted with vimentin and CD34. It has no malignant potential although extensive infiltration may occur. The etiology is unknown. We discuss the clinical, the pathological aspects and the possible etiological factors of the inflammatory fibroid polyp.

[Value of admission for observation in the management of acute abdominal right iliac fossa pain. Prospective study of 205 cases]. / Douleurs aiguës de la fosse iliaque droite: intérêt de la surveillance clinique hospitalière. Etude prospective de 205 cas.

INTRODUCTION: Because of the potential severity of acute appendicitis, many authors recommend the broad use of appendectomy. In this case, 15 to 20% of appendectomies are ultimately found to have been unnecessary. Hospital observation with repeated clinical and laboratory exams can be useful for patients with atypical clinical presentation. This paper assesses our approach, in which some patients with pain in the right iliac fossa (RIF) are admitted for observation before a decision about appendectomy. PATIENTS AND METHODS: All patients (205 cases) admitted from March 2002 through February 2003 for acute abdominal pain of the RIF were included in this prospective study. The 120 women and 85 men (sex ratio=0.7) had a mean age of 27 years. We classified the patients into 3 groups: those who had an emergency appendectomy, those who had surgery after an observation period, and those discharged without appendectomy after observation. RESULTS: The first group included 110 patients: 63% had a (rectal) temperature greater than 38 degrees C; 44% had guarding of the RIF and 87% elevated white blood cell counts (>10000/mm3). At surgery, appendicitis was diagnosed in 92%. After a mean delay of 36 hours of observation, 50 of the patients in the second group underwent surgery: 44% with (rectal) temperature > 38 degrees C, RIF guarding in 8%, and elevated white blood cell count (>10000/mm3) in 74%. In this group, 94% were diagnosed with appendicitis during surgery. Forty-five patients were discharged without surgery after 36 hours of observation. COMMENTARY: In this study, pain and RIF guarding, associated with temperature greater than 38 degrees C and elevated white blood cell counts, were predictive of appendicitis in 96% of cases. Admission for observation of patients with atypical presentation avoided 45 unnecessary appendectomies (22%).

[Treatment of primary and secondary malignant tumor of the liver. Opinion of the surgeon]. / Le traitement des tumeurs malignes primitives et secondaires du foie. Le point de vue du chirurgien.

Hepatocellular carcinoma is the most frequent primitive cancer of the liver. This tumor mainly develops in cirrhotic liver that is a true precancerous state. Treatment can be surgical or not surgical. Orthotopic liver transplantation is the only treatment that definitively address both the metachronous occurrence risk of hepatocellular carcinoma and the underlying disease. Liver metastases from colorectal carcinomas are the most frequent secondary tumors. Only complete resection offers the potential for curative treatment of these metastases.

[Results of laparoscopic treatement of common bile duct lithiasis. Report of 30 cases]. / Resultats du traitement laparoscopique de la lithiase de la voie biliaire principale. Etude de 30 cas.

AIM: The aim of this retrospective study was to report the results of the laparoscopic management of common bile duct stones in an unicentric series of 30 patients. METHODS: From January 2001 to April 2004. 30 patients: 23 women, 7 men (mean age: 54 years). underwent a common bile duct exploration for lithiasis through a laparoscopic approach. The patients were hospitalized for angiocholitis (n = 12), cholecystitis (n= 4), jaundice (n = 4), pancreatitis (n = 3), abnormality of hepatic tests (n = 7). All the patients underwent an intra operative cholangiography. Removal of the stones was tried in 30 cases through a choledochotomy. never through the cystic duct, using Dormia and Fogarty catheters. External biliary drainage with T tube (kehr) and postoperative cholangiography was done systematically. RESULTS: In 21 patients (70 %), removal of the stones was laparoscopically successful. The average diameter of the common bile duct was 10.5 mm (range 6-20 mm). The median number of stones was 5 (E: 1-12). The median operation time was 180mn (range 150-300mn). In 9 patients, a conversion into laparotomy was necessary for several reasons. In 2 patients with residual common bile duct, the stones were treated successfully by endoscopic sphincterotomy. There was no mortality and the morbidity rate was 10 %. The mean postoperative hospital stay was 14.7 days (range 7-18days) and 13.3 days in case of successful laparoscopic management. CONCLUSION: In 70 % of the patients, the treatment of the common bile-duct lithiasis could be achieved laparoscopically, but conventional approach and endoscopic sphincterotomy are still useful in case of failure of the laparoscopic management.